The present study was performed on 10 cases with germ cell tumor of the mediastinum who were operated on in our Surgical Department.
Computed tomography was useful in distinguishing between benign and malignant tumors in preoperative diagnosis. Useful information was obtained particularly on tumor density and margin as well as on the fatty plane around the tumor. All of the benign teratomas had cystic lesions in the masses.
Angiographically, dilatation of the thymic artery was not found in any cases of germ cell tumor, suggesting that the tumor can be distinguished from thymoma on this basis.
Alpha-fetoprotein and human chorionic gonadotropin were useful tumor markers not only for the diagnosis but also for the evaluation of therapeutic effect and prognosis of malignant germ cell tumor.
Surgical removal was performed in all of the benign teratomas of which prognosis was excellent, whereas surgical removal was not effective in malignant non-seminomatous germ cell tumors.

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A study was performed on the clinical characteristics and prognosis of 27 patients aged 70 years and over who underwent surgery for peptic ulcer.
Seventeen patients had gastric ulcers, six duodenal ulcers, and four gastric and duodenal ulcers. The male-to-female ratio was 2.4:1.
Twenty patients (74.1%) had no past history of peptic ulcer before 70 years of age. Seventeen patients (63.0%) had epigastric pain, the commonest presenting symptom. Fourteen patients (51.9%) had suffered from the disease for less than six months, nine (33.3%) of these for less than one month.
Bleeding (ten patients) and perforation (eight patients) accounted for 66.7% of indications for operation and 14 patients, six of those with bleeding and all of those with perforation, underwent emergency surgery. All patients with perforation developed peptic ulcers for the first time after 70 years of age and most of the perforating ulcers were located in the antrum of the stomach or the bulbus of the duodenum.
Twenty-two patients (81.5%) had associated disease before surgery.
The mortality of emergency surgery was 28.9%, and an extremely high mortality, 50.0%, was observed for perforation.

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In 549 operated cases of gastric cancer, invasion to adjacent organs was found in 96 (17.5%). Cases of gastrectomy combined with resection of adjacent organs numbered 33 of which 11 were curative and 22 non-curative. The organs of invasion in 52 resected cases were the pancreas in 39, the transverse colon in 16 and the liver in five. The cases of total gastrectomy were 25 and those of distal gastrectomy were eight in 33 combined resection cases. The organs of combined resection were the pancreas and spleen in 20, the transverse colon in 13 and the liver in three. Histological invasion to the adjacent organs was detected in 69.7% (23/33). In terms of prognosis, resected cases were better than non-resected cases; cases of combined resection of invaded organs were better than those without combined resection, and curative cases were better than non-curative cases. Good prognosis resulted from combined resection of invaded organs.

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Intestinal Behçet's disease, one of the secondary symptoms of Behçet's disease, is a major cause of death, as are the neural and vacular types. We investigated the specificity of HAL in 33 patients with Behçet's disease and compared HLA in 19 cases of intestinal Behçet's disease with that in 14 non-intestinal cases with no evidence of enteritis. In adition, HLA in inflammatory bowel disease (170 cases of ulcerative colitis and 47 of Crohn's disease) was compared with that in intestinal Behçet's disease. In the Behçet's disease group, HLA exhibited significant correlations to A31, B51 and DR4. In relation to the association of enteritis, the intestinal Behçet's group showed significant decreases in A31, DRW8 and DRW52 compared with the non-intestinal group, whereas the rates of DR4 and B51 in these two group were significantly higher than those in 310 normal individuals. The intestinal Behçet's disease group demonstrated correlations of HLA to B51 and DR4; the ulcerative colitis group, correlations to A24, BW52, DR2 and DQW1; and the Crohn's disease group, correlations to A31, BW61, DR4, DRW53 and DQW3. Thus, these three groups showed different HLA specificities.

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In 72 cases of colorectal cancer followed for pre- to postoperative changes in CEA level, the relation of the level one month after surgery to prognosis was studied.
1. The mean preoperative CEA level of the radical surgery group (2.5±2.1ng/ml) was significantly lower than that of the non-curative surgery group (15.1±21.9 ng/ml).
2. The CEA level one month after surgery was low in 44 (93.6%) of the 47 cases in the radical surgery group, whereas in the non-radical surgery group, only 56% of the cases showed decreases.
3. Irrespective of the type of surgery, the postoperative survival period (9.8±6.2 months) in the cases showing a higher CEA value one month after surgery than the preopeartive value was much shorter than that in the cases showing a lower postoperative CEA level (22.1±11.5 months). The CEA level was thus useful for prognostic evaluation.
4. Postoperatively, liver metastasis was frequent among the cases showing an increase of over 20ng/ml in CEA, and metastasis to other organs, regional invasion and cancerous peritonitis were prevalent among the cases exhibiting an increase of less than 20ng/ml. Most cases of regional recurrence showed a normal value, requiring additional examinations.

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Post-operative complications were evaluated in 221 patients who underwent surgical resection of colon cancer between January 1976 and December 1984.
Major complications (re-operation, need for intensive respiratory or circulatory care etc.) were divided from minor complications.
Local complications including wound infection, ileus, leakage, etc., occurred in 60 patients (27%). Many cases of ileus or leakage were responsible for major complications. All cases of ileus obtained complete cure, but two of 11 cases of leakage developed multiple organ failure. Systemic complications including pneumonia, heart failure, renal failure, etc., occurred in 15 patients (6.8%). Of those, as many as five patients had major complications.
According to the data described above and some other data, leakage, intraperitoneal abscess, emergency operation for perforation and age above 70 years were considered risk factors for major complications, and/or multiple organ failure.

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Of 83 cases of metastatic liver cancer treated by the authors, 39 with the primary lesion in the stomach and 33 in the large intestine were compared with regard to prognosis. The prognosis of hepatectomized patients was also evaluated. The group with metastatic liver cancer originating in the large intestine showed significantly better results than those of the group with the primary focus in the stomach. Examination of differentiating adenocarcinoma exhibiting a high frequency of liver metastasis revealed differences in properties, such as the stage of primary lesion and metastatic liver lesion, between the stomach and large intestine. The prognosis of the hepatectomized patients with liver metastasis was better than that of the non-hepatectomized patients. Of 14 hepatectomy cases, the large intestine (11) was the most frequent site of primary lesion, and these 11 cases showed satisfactory prognosis. Liver metastasis of colorectal cancer was the best indication for hepatectomy. Partial resection was thought to be a sufficient procedure for hepatectomy, since no prognostic difference was observed between segmental and partial resection.

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A retrospective study of 36 cases of pancreatic cyst treated during the recent 13 years was performed from the aspects of imaging and treatment. Visualization of the internal structure by abdominal echography and CT was rare in inflammatory cysts, but frequent in neoplastic cysts. Differentiation between mucous and serous cystadenoma on the basis of properties was possible. Retrograde pancreatography, which disclosed the entire pancreatic ductal system, was important in determining surgical procedure. Angiography was effective for differentiating between benign and malignant cysts, even though some of the inflammatory cysts suggested malignant findings. The most frequent therapy in cases of inflammatory cyst was internal fistulization, with additional side-to-side pancreaticojejunostomy as a procedure for underlying chronic pancreatitis. Neoplastic cysts were resected in all cases, and the procedure for pancreatic cancer was modified for use in the cases of cystic adenocarcinoma. The remote postoperative results in the cases of inflammatory cyst were satisfactory: symptomatic improvement was found in 83.1% of patients and occupational rehabilitation in 70.6%. All of the three patients with cystic adenocarcinoma are well, including the one surviving a maximum period of 4 years and 10 months.

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By December 1986, four patients with Insulinoma were admitted to our hospital. All the patients, a man and three women, complined of unconciousness on fasting. The age range was 22-68 years (mean, 39.5 years). They were diagnosed as insulinoma by laboratory examinatin. To determine the localization of tumors we used ERCP, US, pancratic scintigraphy, angiography and CT scan. Although the site of the tumor was identified in three cases by angiography, in one of them the tumor stain was obscure. We then applied percutaneous trnshepatic portal-venous sampling (PTPVS) to confirm the site of tumor. This procedure demonstrated stepped up insulin at the superior pancreatoduodenal vein. The other method did not demonstrate the localization of tumors in four cases. Enucleation in two cases, distalpancreatectomy and pancreatoduodenctomy were performed in one case each. Bilialy fistula and pancreatic fistula were complications but were treated conservatively. Three of the four patients (one woman's prognosis is unknown) have shown a good course.

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We experienced a case of subclavian steal syndrome (SSS) with specific obstruction of the right proximal subclavian artery. The patient was a 44-year-old man who complained of numbness of the right hand. Right carotid-subclavian artery anastomosis was performed under general anesthesia. Postoperatively, the patient was free from the symptom. The obstructed segment was a fibrous cord 3.5cm in length and 2mm in diameter. The cause was thought to be congenital malformation.
In a review of the Japanese literature, 73 cases were reported from 1965 to 1986, and the pathophysiology, was described in 64 cases as follows: Aortitis syndrome in 28 cases (43.8%), arteriosclerotic lesions in 22 (34.4%), congenital malfomations in 13 (20.3%), and iatrogenic lesion in one (1.6%). These data indicated that of arteriosclerotic lesions and the occurrence of congenital malformations was not as rare as previously thought.
Of 13 cases with congenital malformations, three had a similar aspect to our case. All four cases were male (aged 34, 29, 43 and 44 years) with a fibrous cord at the right proximal subclavian artery. None had cadiovascular anomaly.

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We treated a patient with atrial septal defect (ASD) who had repeated congestive heart failure starting in infancy, but showed symptomatic improvement by early surgical treatment. The patient was a 20-month-old female. At the age of 10 months, she was hospitalized for severe cardiac insufficiency. Detailed cardiac examination at 12 months of age revealed ASD with a pulmonary arterial pressure of 36/10 (22) mmHg, a ratio of pulmonary to systemic flow rates of 2.5 and a left-to-right shunt of 66%. Improvement in the symptoms of cardiac insufficiency and the absence of pulmonary hypertension justified a non-surgical follow-up. At the age of 19 months, she was again admitted with cardiac insufficiency and was treated by medical therapy without success. Since cardiac catheterization performed again detected an elevation of the pulmonary arterial pressure from the previous level to 46/10 (24) mmHg, radical surgery was carried out at the age of 20 months. The surgical procedure consisted of direct suture of a 25×15mm ASD in the center under simple deep-hypothermia. The postoperative course was satisfactory, with marked improvement in clinical symptoms.

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A case of a thoracoabdominal aortic aneurysm (Type IV on the Crawford classification) that was operated on successfully is reported. The patient was a 65-year-old male. The approach to the aneurysm was made accodring to the spiral opening method of Stoney. Arterial reconstruction was performed using DeBakey's method. During the operation, neither extracorporeal circulation nor temporary shunt was used. A pair of intercostal arteries was revascularized using an artificial graft. Although the graft was occluded during the operation, the patient did not suffer paraplegia. Postoperatively, liver and renal function deteriorated, but were improved by medical treatment.
About 200 thoracoabdominal aortic aneurysmal operations have been reported in Japan. Although in general intercostal arterial revascularization is difficult in DeBakey's method, the use of this arterial reconstruction is reported.

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Retroperitoneal malignant paraganglioma is a rare disease that derives from the neurogenic tissue. Chief complaints of the previously reported cases were palpable mass and abdominal pain. There were no reported cases in Japan in which chief complaint was remittent fever.
A 65-year-old man visited the Department of Surgery of Niigata University Hospital with remittent high fever and left lateral abdominal pain. Both abdominal echography and computed tomography revealed a round, fist-sized retroperitoneal tumor. Laparotomy was done and a tumor measuring 8cm×8cm×7cm surrounded by the pancreas, spleen, left kidney, abdominal aorta and regional lymph nodes was dissected. Pathological diagnosis of malignant paraganglioma was made by routine and specific staining methods. The postoperative course was uneventful, remittent fever began to subside on the 6th postoperative day and the patient was discharged on the 18th postoperative day.
Retroperitoneal tumors have various origins and show various pathological findings. In addition, para-ganglioma contains numerous vessels and so massive bleeding will occur if it is injured during operation. Sufficient information about the location, blood supply and invasion to adjacent organs should be obtain preoperatively in order to avoid such an accident.

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The patient is a 69-year-old female. A tumor of 5cm in diameter was found under the skin of the left lumbar region at the age of 60, in 1977, and extirpation was performed. The pathological diagnosis was fibrosarcoma, and additional resection of the surrounding tissue was performed the following day. Metastasis was found in the left deltoid muscle when she was 66, in 1982, and extirpation was performed. Metastasis was again found in the left retroperitoneal cavity when she was 68, in 1984, and extirpation was performed. Local recurrence was found in the left retroperitoneal cavity and metastasis was found in the right rectal muscle of the lower abdomen when she was 69, in 1986, and extirpations were performed.
Fibrosarcoma, in general, shows local recurrence and hematogenous metastases to the lung, bone, and other areas, and cases that show metastases have a poor prognosis.
It is interesting that our case did not show metastases to the lung and bone, but to the soft tissues, as many as three times, and is still alive nine years after onset.

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It is known that non-Hodgkin's lymphoma patient presenting as a bulky mass has a poor prognosis, even if it is localized, because of its poor response to conventional treatment. A case of non-Hodgkin's lymphoma with a bulky mass in the left lumbar region is presented. She responded well to a combined radiochemotherapy. A 64-year-old female who complained of a left lumbar mass was admitted to the hospital. The mass was smooth at the surface and hard on physical examination. On CT scan a solid mass 11cm in diameter involving the rib had pressed the left kidney. A biopsy disclosed non-Hodgkin's lymphoma of diffuse large cell type, 50 Gy of radiation followed by Vincristine, Endoxan, Predonine and Adriamycin (VEPA) chemotherapy was given and the mass disappeared on CT scan by the end of the 9th cycle of chemotherapy. The clinical course after the 20th cycle of chemotherapy was uneventful, without any evidence of recurrence and metastasis. Careful follow-up is being observed.

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Intramural hematoma of duodenum is seldom reported in the Japanese literature. This disease occurs in children or following abdominal trauma in the majority of cases.
A 18-year-old man with traumatic duodenal hematoma underwent successful conservative treatment for 59 days. In this report, we review the diagnosis and therapy of the 47 cases previously reported in Japan.
In addition to upper gastrointestinal contrast roentgenogram, CT and ultrasonography were useful in the diagnosis and follow-up of this disease. As a result, conservative treatment is recently on the increase.

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Traumatic intramural hematoma of the duodenum is rare and occurs mostly in children. This paper reports two cases diagnosed soon after blunt abdominal trauma.
Case 1. A 7-year-old male was admitted to the hospital because of abdominal pain and vomiting following a history of falling on the handlebars of his bicycle. Case 2. A 15-year-old male was admitted because of abdominal pain and vomiting after accidentally hitting his abdomen several times.
In these cases, US and CT examinations soon after trauma helped to diagnose large intramural hematomas of the duodenum and jejunum.
The examinations were also useful to comfirm the diagnosis of hematoma and duodenal obstruction. An upper GI series did not see to be necessary. Therefore, conservative therapy by nasogastric suction and intravenous fluids were soon stopped. The large hematoma and duodenal obstruction led to emergent surgical therapy. These patients were restored completely by surgical evacuation of the hematoma shortly after admission.
Previously, intramural hematoma of the duodenum was diagnosed only by upper GI series, but as seen in these cases, it is possible to diagnose this disease and to comfirm the quantity of the hematoma by US and CT.
The situation of hematoma is considered an important factor in surgical management. Surgical therapy results in shortening of the hospitalization in cases with large hematoma.

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Eight patients suffered from complications at various after intestinal bypass surgery. Complications include bacterial overgrowth syndrome and chronic pseudo-obstruction. They underwent reconstructive opeartions with end-to-end anastomoses, with or without resection of the bowel loops. After surgical correction of the bowel, six patients developed ileus and five had severe motor disturbances of the intestine for a mean duration of 37 days. However, no anatomical obstruction was detected by subsequent X-ray examination. These patients, without additional surgery, healed completely through careful management of electrolyte balance and nutrition.

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Eleven cases of appendicitis with a palpable mass treated by combined bowel resection were retrospectively studied. The indications for combined bowel resection were the direct spread of appendiceal infection to the cecum in 2 cases; abscess formation in the posterior portion of the cecum, with the ileal region becoming a mass due to the inflammatory tumor in 3 cases; appednicitis with tumor formation in 2 cases; and malignant tumor in 2 cases. Of the remaining two patients, one underwent reoperation for intestinal fistula and the other for an inflammatory tumor resulting from the inflammation remaining in the cecum. While combined enterectomy should be avoided for benign appendicitis, however extensive the inflammation may be, we occasionally select this procedure for advanced appendicitis with a palpable mass. In such cases, appendectomy is performed if possible, and if impossible, drainage or combined bowel resection is selected for appendicitis spreading to the cecum and for that with abscess formation. Combind bowel resection is carried out for appendicitis with tumor formation and suspected malignant tumors.

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A patient with vascular ectasia with three longitudinal ulcers in the right side of the colon was treated. This is the second documented case of vascular ectasia accompanied by longitudinal ulcer in the world literature. The patient was a 71-year-old female with chief complaints of melena, abdominalgia persisting for two days and diarrhea followed by melena. Examination revealed mild anemia of the palpebral conjunctiva and tenderness in the right lower quadrant of the abdomen. Multiple irregular shallow ulcers were found from the cecum to the ascending colon by emergency endoscopy of the colon, and poor dilatation of the same area was detected by barium enema examination. Right hemicolectomy was performed. Resected specimen showed three longitudinal ulcers from the cecum to the ascending colon. Pathologically, the ulcers were UL II in depth and accompanied by vascular dilatation and coil-like changes; the diagnosis of vascular ectasia was made. The patient was discharged in improved condition on the 39th postoperative day. Pyrexia occured two months after discharge and persisted thereafter. The diagnosis of pancreatic cancer and its liver metastasis was established as a result of exploratory laparotomy. The patient died of cancer eight months after the initial operation.

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A 65-year-old male patient with chief complaints of pyrexia and epigastralgia was treated. Examinations revealed anemia, an increased erythrocyte sedimentation rate, leukocytosis, polyclonal hyperimmunoglobulinemia and reactive hyperplasia of plasma cells in the bone marrow. Abdominal CT visualized a low-density area with an obscure demarcation in the posterior segment of the right hepatic lobe, and angiography showed vascular hyperplasia in the posterior branch of the right hepatic artery. Under a suspicion of liver abscess, exploratory centesis was preformed, but neither purulent discharge nor definite formation of an abscess cavity was found. By needle biopsy, the liver tissue was found to have been replaced by an inflammatory granulation tissue consisting of many plasma cells, lymphocytes and fibroblasts, but no microabscesses were observed. These findings led to the diagnosis of inflammatory pseudotumor of the liver (histopathologically, plasma cell granuloma). As a possible etiology of this disease, it was speculated that some immunological abnormality was involved, for our case presented with polyclonal hyperimmunoglobulinemia and hyperplasia of plasma cells in the bone marrow.

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A patient with mucous-producing cholangiocarcinoma associated with obstructive jaundice due to massive mucous is reported in the context of the available literature.
The patient, a 62-year-old man, was admitted to hospital with main complaints of jaundice and fever. Although PTC drainage was carried out, the drainage was poor, and the patient was obliged to undergo drainage of the biliary tract. The patience was diagnosed as having mucous-producing cholangiocarcinoma as a result of postoperative examination by endoscopy through the T-tube fistula. After the jaundice had been reduced, the tumor was resected by extended left lobectomy. The postoperative course was favorable, and the patient is now under observation on an outpatient basis.
It is rare that obstructive jaundice occurs due to mucous produced from cholangiocarciona, and only several cases have been reported.

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Pancreatitis associated with pregnancy is rare. We treated a patient who developed acute pancreatitis in the latter stage of pregnancy and was found to have hyperparathyroidism by a subsequent study. The patient was a 25-year-old female who showed epigastralgia in the 33rd week of pregnancy. Despite symptomatic therapy, symptoms were aggravated, accompanied by a barely audible fetal heart sound. Emergency laparotomy performed for abruption of the placenta revealed voluminous cloudy ascites, and the epigastric region, following fetal delivery, disclosed an enlarged pancreas, with partial necrosis. The diagnosis of acute pancreatitis associated with pregnancy was established, and pancreatic mobilization and intraperitoneal drainage were performed. Post-operative hematology disclosed elevations of serum Ca and parathyroid hormone, indicating an additional complication of hyperparathyroidism. Parathyroid adenoma was resected 21 months after the opearion for acute pancreatitis.

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